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RE: Revision of Instructions - clinical implications

by Pablo Pazos Gutierrez :: Rate this Message:

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But we are talking about the openEHR model, so we should consider the semantics of the terms we use based on those semantics instead of redefine them on every discussion. That's what a standard is for: defining a common language so we have no misunderstandings for differences on interpretation (= avoid ambigüity).

The states you mention are modeled by the openEHR model already. There are 3 different concepts: the initial instruction, the actions made for that instruction, and the current execution state for that instruction, determined by the actions taken. The record of those 3 different elements should be done separately, because you want to have the execution history of the instruction, not only the current state. The execution history is recorded in the actions taken. This is needed for audit trail, for medico-legal reasons, and to detect problems on the care process.

I think storing all the information in one class doesn't solve the problem and leaves out the historical information.

--
Kind regards,
Ing. Pablo Pazos Gutiérrez
LinkedIn: http://uy.linkedin.com/in/pablopazosgutierrez
Blog: http://informatica-medica.blogspot.com/
Twitter: http://twitter.com/ppazos

Date: Sat, 10 Dec 2011 22:18:54 +0000
From: sjagannathan@...
Subject: RE: Revision of Instructions - clinical implications
To: openehr-clinical@...

Not an expert on' openEHR semantics'
But in simple terms it is still a matter of something + an attribute( in this case the tense) ie Procedure+ordered/instructed
               + done,
               + not done
               + proposed
               + postponed
               + suggested etc

I wasn't trying to change any open ehr rules, but was just looking at it from a straightforward, logical and simplistic view to try and avoid ambiguity, confusion and duplication.

Cheers

Jag

Dr. S Jagannathan

--- On Sat, 10/12/11, pablo pazos <pazospablo@...> wrote:

From: pablo pazos <pazospablo@...>
Subject: RE: Revision of Instructions - clinical implications
To: "openehr clinical" <openehr-clinical@...>
Date: Saturday, 10 December, 2011, 21:51

Those are not the semantics used in openEHR: http://www.openehr.org/releases/1.0.2/architecture/rm/ehr_im.pdf

In the openEHR RM the ACTION is the record of something done: a procedure, a study, etc. An INSTRUCTION is the record of the order of that procedure or study.

--
Kind regards,
Ing. Pablo Pazos Gutiérrez
LinkedIn: http://uy.linkedin.com/in/pablopazosgutierrez
Blog: http://informatica-medica.blogspot.com/
Twitter: http://twitter.com/ppazos

Date: Sat, 10 Dec 2011 17:02:57 +0000
From: sjagannathan@...
Subject: Re: Revision of Instructions - clinical implications
To: openehr-clinical@...

When you instruct someone do to something then it is an action.

Jag

--- On Sat, 10/12/11, Thomas Beale <thomas.beale@...> wrote:

From: Thomas Beale <thomas.beale@...>
Subject: Re: Revision of Instructions - clinical implications
To: openehr-clinical@...
Date: Saturday, 10 December, 2011, 16:49

Instruction defines what Activities should be performed. Actions record
the execution of those activities, which might not be exactly the same
as what was ordained. So Instruction = intended; Action = actual.

- thomas

On 10/12/2011 16:00, S JAGANNATHAN wrote:
> Isn't 'Instruction' itself an action?
>
> Jag

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